To ensure appropriate documentation for professional services rendered, e.g., in a hospital Emergency Department, clinicians are required to document particular elements based upon a patient's clinical presentation and the reason for the patient's visit. Based upon the quantity of documented elements within components and subcomponents particularly set forth in the CMS 95 Coding Guidelines for Professional Evaluation and Management (E&M) Coding, a patient visit is attributed a coding level. Emergency Department coding levels typically range from one to six, with level six indicating a critical patient. While in order to ensure as high a quality of care in the Emergency Department as possible it is crucial for visit documentation to be accurate and complete, often times it is difficult for a clinician to know whether or not the amount of documentation that has been completed is sufficient to attain an appropriate coding level in association with a patient's visit.
The issue is essentially two-fold. First, with the plethora of potential patient presentations and reasons for visits that exist in an Emergency Department, it is difficult for clinicians to maintain current knowledge of which presentations are to be coded at which coding levels. That is, it is difficult for clinicians to know what a so-called “typical” coding level (or “typical” visit level) should be for each patient presenting in the Emergency Department. Second, even if the clinician is aware of what a patient's “typical” visit level should be, it is difficult for the clinician to know if the elements that have been documented are sufficient to attain that level.
Coding meters exist in the marketplace today that allow a clinician or other individual to input information indicative of the quantity and nature of elements that have been documented in association with a patient visit. Subsequently, the coding meters output a visit or coding level in accordance with the CMS 95 Coding Guidelines which is supported by the documentation input. However, such coding meters can only offer an after-the-fact assessment whereby, if the documentation is insufficient to attain the appropriate coding level, the clinician must revisit the patient's chart and attempt to rectify the inconsistency. As such, this method is highly inefficient and presents ample opportunity for under-coding a patient visit.
Other solutions currently available in the marketplace offer a mechanism whereby the coding level may be checked prior to a clinician signing off on the patient's chart. However, this, too, is not a real-time solution the clinician may utilize at the time of documentation to ensure all appropriate measures are being taken to ensure the highest quality documentation. Thus, the step of having to check after-the-fact whether adequate documentation has been completed still must be performed.
Therefore, a system and method which offers clinicians a real-time view of a typical visit level associated with a reason for a patient's visit, as well as the E&M coding level associated with the current documentation would be desirable. Additionally, a system and method for identifying and indicating to a clinician, at the time the clinician is documenting a patient visit, those areas of documentation that are incomplete for achieving the appropriate E&M coding level would be advantageous.